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Coding Scenarios for STD Clinic Visits Presented by: Lissa Singer, APRN (WHC), MBA, CPC-I, CPCO
Agenda Case Study 1 male without symptoms Case Study 2 male with symptoms Case Study 3 female with exposure Other Common Denial Scenarios Q&A
Learning Objective Participants will be able to review denied claims for STD services and generate alternative coding options.
Disclaimer The coding guidelines, interpretations, and recommendations provided are presented as a guide only. Your actual coding decisions are your sole liability and responsibility. Lissa Singer and JSI do not accept any liability or responsibility in this regard.
Case Study 1 50-year old male without symptoms (new patient) Chief Complaint: HPI: ROS: No symptoms, in a new relationship, just wants to be checked Context: wants STI screening GU: denies discharge, scrotal pain or swelling, denies pain with urination PFSH: Past Medical: + for chlamydia & gonorrhea 2014 Social Hx: MSM+, age at 1st intercourse 18, total lifetime partners TNTC, oral and anal sex, condoms only sometimes
Case Study 1 (continued) 50-year old male without symptoms (new patient) Exam: Psyche: alert & oriented no acute distress Assessment and Plan: 1. STI screening: urine chlamydia and gonorrhea (performed in house - both negative) & Rapid HIV (non reactive) 2. STI counseling: spent 15/20 minutes discussing - HIV test results, condoms, STIs and safer sex
Considerations What is the ACA coverage regarding this patient? HIV screening for everyone ages 15 to 65, and other ages at increased risk STI prevention counseling for adults at higher risk If ACA covered no cost sharing
Considerations Would the ACA coverage be different if he was 16 years old? STI prevention counseling and screening for adolescents at higher risk HIV screening for adolescents at higher risk Would it be different if he was low risk? Likely not covered
Coding Options CPT code visit based on history, exam & medical decision making CPT Code ICD 10 Code ICD 10 Code Coverage 99201 (visit) Modifier 33 (private insurance only identifies a screening service) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 87591 (urine gonorrhea) Modifier 33 (private insurance only identifies a screening service) Modifier 90 (labs sent out) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 87491 (urine chlamydia) Modifier 33 (private insurance only identifies a screening service) Modifier 90 (labs sent out) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z11.4 Encounter for HIV screening Z72.52 High-risk homosexual behavior ACA covered; no cost sharing
Coding Options CPT code visit based on time spent counseling CPT Code ICD 10 Code ICD 10 Code Coverage 99201 (visit) Modifier 33 (private insurance only identifies a screening service) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 87591 (urine gonorrhea) Modifier 33 (private insurance only identifies a screening service) Modifier 90 (labs sent out) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 87491 (urine chlamydia) Modifier 33 (private insurance only identifies a screening service) Modifier 90 (labs sent out) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z11.4 Encounter for HIV screening Z72.52 High-risk homosexual behavior ACA covered; no cost sharing
Coding Options CPT code visit based on time spent counseling using preventive counseling codes CPT Code ICD 10 Code(s) ICD 10 Code Coverage 99401 (preventive counseling visit) Modifier 33 does not apply Z71.7 HIV counseling Z71.89 Other specified counseling Z72.52 High-risk homosexual behavior ACA covered; no cost sharing 87591 (urine gonorrhea) Modifier 33 (private insurance only identifies a screening service) Modifier 90 (labs sent out) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 87491 (urine chlamydia) Modifier 33 (private insurance only identifies a screening service) Modifier 90 (labs sent out) Z11.3 Encounter for screening for infections with sexual mode of transmission Z72.52 High-risk homosexual behavior Not ACA covered; cost 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z11.4 Encounter for HIV screening Z72.52 High-risk homosexual behavior ACA covered; no cost sharing
Case Study 2 20-year old male with symptoms (established patient) Chief Complaint: HPI: ROS: PFSH: Wants to be checked for STIs, thinks he has a UTI Pain/onset: 4 days ago Location: penis Quality: burning GU: denies discharge, has pain with urination Constitutional: denies fever Past Medical: none significant Social Hx: MSM+, MSW+, age at 1 st intercourse 15, total lifetime partners 6, oral and anal sex, condoms infrequently
Case Study 2 (continued) 20-year old male with symptoms (established patient) Exam: Constitutional: 98.5, 82, 107/54 Psyche: alert & oriented no acute distress GU: declined by patient Assessment and Plan: 1. Urine dip stick: negative 2. STI testing: urine chlamydia and gonorrhea (performed in house both positive) & rapid HIV (non reactive) 3. RX: Azithromycin 1GM PO & Ceftriaxone 250MG IM 4. STI counseling: spent 15/25 minutes discussing HIV test results, condoms, STIs and safer sex, treatment and partner treatment
Considerations What is the ACA coverage regarding this patient? This is not a screening visit, despite the fact the patient wants to be checked, he has symptoms. If he is expecting a screening visit (no copayment or cost sharing), he should be notified at check-out. The co-payment or cost sharing will depend on the coding scenario used and the patient s insurance (flat rate vs. percentage).
Considerations Would the ACA coverage be different if he had no symptoms? HIV screening for everyone ages 15 to 65, and other ages at increased risk STI prevention counseling for adults at higher risk If ACA covered no cost sharing Would the ACA coverage be different if he was 15 years old and had no symptoms? STI prevention counseling and screening for adolescents at higher risk HIV screening for adolescents at higher risk
Coding Options CPT code visit based on history exam and medical decision making CPT Code ICD 10 Code ICD 10 Code Coverage 99213 (visit) A56.01 Chlamydial cystitis and urethritis A54.00 Gonococcal infection of lower genitourinary tract, unspecified 87591 (urine gonorrhea) Modifier 90 (labs sent out) A54.00 Gonococcal infection of lower genitourinary tract, unspecified 87491 (urine chlamydia) Modifier 90 (labs sent out) A56.01 Chlamydial cystitis and urethritis 81002 (urine dipstick) A56.01 Chlamydial cystitis and urethritis A54.00 Gonococcal infection of lower genitourinary tract, unspecified 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z11.4 Encounter for HIV screening Z72.53 High-risk bisexual behavior ACA covered; no cost sharing
Coding Options CPT code visit based on time spent counseling CPT Code ICD 10 Code ICD 10 Code Coverage 99214 (visit) A56.01 Chlamydial cystitis and urethritis A54.00 Gonococcal infection of lower genitourinary tract, unspecified 87591 (urine gonorrhea) Modifier 90 (labs sent out) A54.00 Gonococcal infection of lower genitourinary tract, unspecified 87491 (urine chlamydia) Modifier 90 (labs sent out) A56.01 Chlamydial cystitis and urethritis 81002 (urine dipstick) A56.01 Chlamydial cystitis and urethritis A54.00 Gonococcal infection of lower genitourinary tract, unspecified 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z11.4 Encounter for HIV screening Z72.53 High-risk bisexual behavior ACA covered; no cost sharing
Coding Options CPT code visit based on history, exam & medical decision making and preventive counseling CPT Code ICD 10 Code(s) ICD 10 Code Coverage 99213 (visit) 25 modifier * not all payers will pay for both on the same day A56.01 Chlamydial cystitis and urethritis A54.00 Gonococcal infection of lower genitourinary tract, unspecified 99401 (preventive counseling visit) Modifier 33 does not apply Z71.7 Human immunodeficiency virus [HIV] counseling Z71.89 Other specified counseling Z72.53 High-risk bisexual behavior ACA covered; no cost sharing 87591 (urine gonorrhea) Modifier 90 (labs sent out) A54.00 Gonococcal infection of lower genitourinary tract, unspecified 87491 (urine chlamydia) Modifier 90 (labs sent out) A56.01 Chlamydial cystitis and urethritis 81002 (urine dipstick) A56.01 Chlamydial cystitis and urethritis A54.00 Gonococcal infection of lower genitourinary tract, unspecified 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z11.4 Encounter for HIV screening Z72.53 High-risk bisexual behavior ACA covered; no cost sharing
Case Study 3 25-year old female with STI exposure (established patient) Chief Complaint: Wants to be checked for STIs. Partner told her he had something but she s not sure. HPI: ROS: Timing: partner treated one week ago, got pills and a shot Context: not using condoms thought relationship was monogamous Severity: feels well, nothing feels wrong Associated S&S: no symptoms GU: denies vaginal discharge or pain with urination Constitutional: denies fever GI: denies abdominal pain or cramping PFSH: Past Medical: G2P1, HTN, Diabetes type 2, has Mirena (since 2016) Social Hx: age at 1 st intercourse 13, total lifetime partners 2, oral and vaginal sex
Case Study 3 (continued) 25-year old female with STI exposure (established patient) Exam: Constitutional: 97.9, 75, 129/84 Psyche: alert & oriented no acute distress GU: ext genitalia WNL, CVX slightly friable, no CMT, white yellow discharge. Mirena string intact, Bimanual AV uterus no pain Assessment and Plan: 1. Friable cervix 2. STI testing: endo cervical swab chlamydia and gonorrhea (send out) & rapid HIV (non reactive), RPR (send out) 3. Will treat presumptively, Rx: Azithromycin 1GM PO & Ceftriaxone 250 MG IM 4. STI counseling: spent 22/40 minutes discussing - HIV test results, condoms, STIs and safer sex, treatment and partner treatment
Considerations What is the ACA coverage regarding this patient? This is not a screening visit, despite the fact the patient wants to be checked, she has been exposed and has signs of infection. If she is expecting a screening visit (no co-payment or cost sharing), she should be notified at check-out. The co-payment or cost sharing will depend on the coding scenario used and the patient s insurance (flat rate vs. percentage).
Considerations Would the ACA coverage be different if she had no exposure and no signs or symptoms? HIV screening and counseling for sexually active women STI counseling for sexually active women Syphilis screening for all pregnant women or other women at increased risk Chlamydia infection screening for younger women and other women at higher risk If ACA covered no cost sharing
Coding Options CPT code visit based on history, exam & medical decision making CPT Code ICD 10 Code(s) ICD 10 Code Coverage 99214 (visit) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 87590 (endocervical swab gonorrhea) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 87490 (endocervical swab chlamydia) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 86592 (syphilis, qualitative) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior ACA covered; no cost sharing
Coding Options CPT code visit based on time spent counseling CPT Code ICD 10 Code(s) ICD 10 Code Coverage 99215 (visit) *may require pre-payment authorization due to high level coding N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 87590 (endocervical swab gonorrhea) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 87490 (endocervical swab chlamydia) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 86592 (syphilis, qualitative) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior 86703 (rapid HIV) Modifier 33 (private insurance only identifies a screening service) Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior ACA covered; no cost sharing
Coding Options CPT code visit based on history, exam & medical decision making and preventive counseling CPT Code ICD 10 Code(s) ICD 10 Code Coverage 99214 (visit) 25 modifier * not all payers will pay for both on the same day N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior covered by insurance; cost 99401 (preventive counseling visit) Modifier 33 does not apply Z71.7 Human immunodeficiency virus [HIV] counseling Z71.89 Other specified counseling Z72.51 High-risk heterosexual behavior ACA covered; no cost sharing 87590 (endocervical swab gonorrhea) Modifier 90 (labs sent out) Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior covered by insurance; cost 87490 (endocervical swab chlamydia) Modifier 90 (labs sent out) Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior covered by insurance; cost 86592 (syphilis, qualitative) Modifier 90 (labs sent out) N72 Inflammatory disease of the cervix Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior covered by insurance; cost Modifier 33 (private insurance only identifies a screening service) Z20.2 Contact with and (suspected) exposure to venereal diseases Z72.51 High-risk heterosexual behavior ACA covered; no cost sharing
Common Denial Scenarios Multiple labs different sources Chlamydia and gonorrhea swabs obtained from multiple locations need an explanation. The payer needs to know why the same test was ordered more than once on the same day as the test itself does not differentiate the specimen source. 76 modifier (repeat procedure or service) 91 modifier (repeat diagnostic laboratory test) 59 modifier (distinct procedural service)
Common Denial Scenarios Multiple annual exams for the same patient If your service line includes annual preventive exams, these are the ONLY ICD10 codes accepted and must be listed as primary Z01.411 Encounter for GYN exam with or without PAP with abnormal findings Z01.419 Encounter for GYN exam with or without PAP without abnormal findings Z00.00 Encounter for general adult medical without abnormal findings Z00.01 Encounter for general adult medical with abnormal findings Women are generally allowed 2 preventive One GYN and one general adult The only thing that differentiates them is the ICD10 code Patients don t always keep track of this
Is it possible to be reimbursed for Expedited Partner Therapy (EPT)? CDC has concluded that EPT is a useful option to facilitate partner management Codes for non face-to-face services Typically for established patients Provided via telephone Rarely reimbursed Coded based on time 99441-99443 Counseling for the partner (who is not present at the visit) should not be included in the patient s total counseling time
CPT Modifier Summary Modifier 25: Significant, Separately Identifiable Evaluation and Management (E &M) Service by the Same Physician on the Same Day EXAMPLE: problem visit (E&M) and preventive visit same day (append to E&M) Modifier 33: Preventive Service EXAMPLE: services rated A or B by U.S. Preventive Services Task Force (append to the E&M or service that is not inherently screening for private insurance only) Modifier 59: Distinct Procedural Service EXAMPLE: multiple labs specimens from different sources (append to the repeated lab) Modifier 76: Repeat Procedure by Same Physician EXAMPLE: multiple labs specimens from different sources (append to the repeated lab) Modifier 90: Reference (Outside) Laboratory EXAMPLE: specimens collected in your office but sent to an outside lab (append to all sendout labs) Modifier 91: Repeat Clinical Diagnostic Laboratory Test EXAMPLE: multiple labs specimens from different sources (append to the repeated lab)
Summary Know the ACA (age and sex matters) Know your payer (ACA interpretation varies by payer) Every STI check is NOT a screening All preventive care has limits (example 99401) Screening labs may be covered but the provider exam may not be Document counseling time (then you ll always have the option to report your CPT code either way)
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Resources List of ACA Preventive Services & CPT Codes A list of STD services-related preventive services covered by ACA without costsharing and their respective billing codes. STD TAC, 2016 http://stdtac.org/wp-content/uploads/2014/06/list-of-aca-preventative-servicesand-cpt-codes-_stdtac.pdf Evaluation and Management Code Selection Overview A decision-making job aid to be used in coding for evaluation and management visits for new and established patients, for codes 99201-99205 and 99211-99215. STD TAC, 2016 http://stdtac.org/wp-content/uploads/2016/05/levels_service_april2016_stdtac.pdf
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